Point-counterpoint: Alternative Mobility Devices (AMDs) for Children

The Need for "Pre-Canes": Fact or Fancy?
Joe Cutter, M.A.

Professionals who each have the same creativity, dedication, energy and interest of their blind children at heart can come to different conclusions about what tool to give their students for travel. The alternatives, however, are not like choosing a Cadillac over a Volkswagen, but rather choosing a car over a wheelbarrow.

"Pre-canes," the term often used interchangeably with "alternative Mobility Devices" (AMDs), implies that the structure and function of the device fits into some continuum of progressing for using travel tools, and that once the child has mastered this device, the cane would be the "next step." After 25 years of experience as an O&M instructor (also certified Teacher of the Blind and Visually Impaired with an M.A. in Teaching the Developmentally Handicapped), I believe that these notions of a "pre-cane" and the readiness skills that go along with it are more fancy than fact. I question what prerequisites actually are needed for the proper use of the cane. Some of the skills that are traditionally considered as prerequisites, such as the sighted guide and protective techniques, are not predictive of independent use of the cane. I consider that a more valid precursor to the cane would be use of a hand-held tool, like the spoon.

We know far less about children in general than we realize. Blind children are particularly vulnerable to assessments that do not develop from observations of children, but rather are imposed upon them by an adult-centered model. My personal experience does not support the notion that some tool must be used prior to a cane or as an alternative to it, and although I am aware of research that addreses this issue, to my thinking none of it validates or substantiates that claim. I would like to see the O&M field examine the criteria that are considered necessary for readiness to use the cane, to determine a more appropriate menu of experiences that promotes independent movement and travel.

When I think of Alternative Mobility Devices, what comes to mind are devices, such as walkers and wheelchairs, that are used by children with motor impairments that affect their walking. Certainly the long cane may assist multiply handicapped blind children as well, as sometimes it can be used in conjunction with these devices. When we apply the term "AMD" to the walking blind child, however, what many O&M professionals really mean is "precane." What they are implying is all the assumptions (which I regard as erroneous) regarding readiness skills that go along with the "precane" concept and which often form a rigid mindset that becomes precarious for the blind child who is receiving instruction.

I have used a variety of tools to experiment with the facilitation of movement in blind children, including the hula hoop, Connecticut Pre-Cane, and the T-shaped cane with roller tip. The components of movement needed to use many of these devices are actually more complex and may demand more sophisticated motor schemes and planning than does the simple design and function of the cane. Certainly a blind child's gate is negatively affected by an inappropriate travel tool. These precane/AMDs often require the use of two hands. Without one free hand, how do you hold onto a railing going up or down the stairs? And for the very young traveler, how do you hold your teddy bear (as all toddlers do) and the Precane/AMD at the same time?

Over the years I have also introduced the cane without a Precane/AMD to many children as early as 16 months of age. As they matured, these children engaged in higher levels of prehension and technical skill, and in time learned appropriate "adult" techniques. My experience tells me that introducing a much later in a child's life presents a barrier to independent movement and the grace and poise that is within then.

All too often the cane is the "tool of last resort." Many professionals choose other tools and skills to address the assumed readiness skills. I did this for a while, and I know the price blind kids paid for a late start with the primary tool that will be their buddy through adulthood. How the child learns is really the central question, how we teach is secondary. We follow their lead.

If we follow the child's lead, the simple design of the cane will afford opportunities for movement that, in my experience, Precane/AMDs do not. Characteristics such as light weight, ease of movement and use, and auditory feedback (resonance) are build into the cane more than any other travel tool. Auditory feedback from the cane is used by blind cane users of all ages.

An essential question is, does the cane facilitate movement when the child is exploring the object world and safely moving about it it? The best way to know is to follow the child's lead. The child who takes to a travel tool "like a duck to water," as many blind children take to the cane, is telling the adult what is best. When a child's travel tool promotes the sense of security and autonomy in free movement, then much more brain power is available for orientation and enjoying the feeling of the movement itself.

All too often when we give the child a Precane/AMD, we send a message to the parent: "Your child is not ready for the cane." Are our assumptions so solid and based upon fact that we should be sending this message? The cane can present a positive, can-do approach. This approach is lacking in our remediation activities, forever targeted at the perceived "limitations" of blind children.

Some professionals advocate the use of Precane/AMDs because they feel that the child who hasn't mastered appropriate "adult" techniques will be unsafe while moving and exploring with the cane. Of course the young child who is being introduced to the cane (at around two years of age) will be under adult supervision when moving about the world - what child that age isn't? All children are supervised in their early movement. The type and amount of supervision will vary with the child, family or school caretaking practices, and the environment. Sighted toddlers often do not initially scan visually or link cognitive and motor plans efficiently, so they will fall and bump into objects. Blind children will do this too with the cane. That's why both sighted and blind children need developmental guidance and exposure to the process of developing appropriate usage of skills and tools. By giving the Precane/AMD to a child are we sending a message that it is safer and more reliable and that therefore less supervision would be needed? That's not the kind of message I would choose to send to parents and school teachers.

In my years of teaching O&M, my thinking has changed about the readiness of blind children to travel with a cane. What changed over time was not the blind child, but my perception of the child's abilities and readiness. It is this area of "what we think we know" that shifts over time. Twenty-five years ago, if I had followed and observed my students more carefully, many more blind children would have had the opportunity to develop independent travel concepts and skills much earlier in life. I now know that the cane, more than any other tool, facilitates the movement of the walking blind child.

Long canes / Adaptive Mobility Devices
Joani Levy (Myers), O&M Specialist

Collaborative use ensures acquisition of concepts and skills required to become a safe, efficient, independent traveler.

There should be no controversy between the use of the standard long cane and an adaptive mobility device (AMD), because each mobility device has its unique positive and negative qualities. Both should be viewed as tools for achieving the skills necessary to become a knowledgeable, safe, efficient long cane traveler. It must be understood, however, that individuals with certain physical challengers may be unable to use the standard long cane effectively, and thus their primary mobility tool would be an AMD.

When a child who has severe visual impairment becomes ambulatory, both an AMD and long cane should be introduced, because both devices provide unique qualities that facilitate the development of environmental awareness, proprioception, and kinesthesia. The AMD facilitates body-width protection, which enables the child to move safely while detecting objects, stairs, and curbs. This protection cannot be provided by the long cane without sophisticated fine or gross motor movement which the child at this stage of development does not yet have. The long cane's size, weight, and design, however, facilitates the acquisition of auditory knowledge that an AMD cannot.

It is not reasonable nor in the child's best interest to think that care givers will monitor the child's movements at all times. Care givers must be highly selective to determine which environments and situations the child should be utilizing which mobility device (or in some cases no device at all). In this way, the child's awareness of the environment expands at a greater rate while promoting the safety of the child and others.

Throughout the period that the child uses an AMD, regardless of age, attempts should be made to integrate the standard long cane. Frequent exposure is necessary because it is difficult to determine exactly when the child has developed the maturity, cognition, fine and gross motor skills, proprioception and kinesthesia that are required before the cane can be used effectively as a primary as a primary mobility device.

EXAMPLES OF USING AMDs:

"Sandy" is a 2-year-old child who has light perception only. She has average intelligence and no additional disabilities. Sandy constantly wanted to move around, particularly toward light sources. She had a limited understanding of the potential dangers imposed within various environments and would move with no protective techniques, using atypical gait patterns. A standard long cane was demonstrated to her but she used it haphazardly, providing her little protection and endangering other children in her preschool class. One-to-one supervision was not available on a regular basis in the school situation to help alleviate the situation.

Sandy was then presented with a basic T-shaped AMD which, like the long cane, has one shaft, but has a T-bar as the tip. This device enabled her to implement the same opportunities at home and school to practice pushing it ahead of her body to maneuver hallways, ramps, stairs, sidewalks and curbs, using her other hand to trail or explore as desired. Her pace increased, movements became more coordinated, and in general she demonstrated more self-assurance.

During the same period of time that Sandy used the T-cane, she practiced using the long cane and was given opportunities to move with the cane while closely supervised. After Sandy had matured (at about age 5), the long cane became her primary travel device.

"Sam" is a nine-year-old child who is totally blind and who has mild cognitive delays. After a few years of receiving cane instruction by another O&M specialist, Sam was still unable to maintain body-width protection while using two-point touch or constant-contact cane technique. Because he held the cane diagonally to his right with his right hand, he never received any information about obstacles directly ahead of his body.

Sam was given a Side Drop-off Tee Cane that I designed last year which is shaped like Sandy's T-cane with two differences: 1) the T-tip was modified such that it wold detect parallel drop-offs and 2) the grip has a short elbow bar extending to the left, which Sam periodically touched with his other hand to check the midline position of the device. Using this device Sam was able to travel safely, efficiently, and independently whenever he desired and, like Sandy, was able to use his free hand to trail and explore. Periodic checks using a long cane were done to assess his ability to maintain proper arm position for body-width protection. Ultimately Sam was able to use a standard long cane as his mobility device.

"Jennifer" is an 8-year-old child who is totally blind, with average cognitive functioning. She has a shortened left heel cord, and muscle tone like that of cerebral palsy affecting her left side and part of her right. Jennifer had also been receiving instruction in the long cane by another O&M specialist for several years but she also was unable to move the cane in a consistent body-width lateral motion, and consistently veered to her left. She had many fears when traveling independently, particularly of contacting descending stairs.

After several more months of training with the long cane as well as frequent intervention by the occupational therapist, a Side Drop-Off T-cane with a T-grip was presented to Jennifer. With practice, this AMD enabled her to maintain body-width protection, a straight line of travel, and the confidence to move independently, even near descending staircases.

Currently, Jennifer uses both the AMD and the standard long cane. She uses the AMD on routes she hasn't yet mastered because her cane technique becomes ineffective when she has difficulties with orientation; using the AMD enables her to concentrate on the environmental landmarks and clues, rather than on cane techniques. She uses the long cane, however quite effectively on short, familiar routes.

Jennifer at all times determines which device she is comfortable using The focus of her O&M program is improving her skills with orientation and with the long cane. It is difficult to predict, however, whether she will eventually use a long cane, an AMD, or both devices depending on the travel situation.

Point-counterpoint: Alternative Mobility Devices (AMDs) for Children

The Need for "Pre-Canes": Fact or Fancy? Joe Cutter, M.A.

Long canes / Adaptive Mobility Devices Joani Levy (Myers), O&M Specialist

EXAMPLES OF USING AMDs:

The Need for "Pre-Canes": Fact or Fancy?
Joe Cutter, M.A.

Long canes / Adaptive Mobility Devices
Joani Levy (Myers), O&M Specialist